I used to be a doctor

I used to be a doctor. Next I was a provider. Now, I’m a non-covered entity. I liked being a doctor…I still do. I never liked being a provider. But being a non-covered entity is a secret victory. I’ll explain.

As a psychoanalyst and psychiatrist, my work depends entirely on confidentiality and respect for people as individuals. Treatment works only when my patients and I are able to explore very personal feelings and thoughts. If my patients are not confident that what they tell me will stay private, they will withhold their thoughts or abort the treatment. In the mid-1980s, when I began practice, what patients told doctors was kept confidential, protected by a compact dating back more than 2000 years, to Hippocrates. Along came private insurers, Medicare, and HMOs—third parties with a financial stake in medical events. Since they were paying out money, they wanted to know what they were paying for, and often began to demand private information before paying. What was personal suddenly became corporate.

To increase profits, insurance companies instituted “managed care” in psychiatry and transferred to shareholders a great deal of the resources that had formerly been spent for health care. Managed care employs many techniques to discourage the use of mental health services. One approach is to have reviewers decide whether patients’ problems meet criteria for “medical necessity” before approving payment for “procedures,” such as psychotherapy. To do this they often demand very personal information, compromising confidentiality. This demand for information, because it threatens confidentiality, can lower quality of care just by existing. Who can talk freely when unseen reviewers are eavesdropping? And, unfortunately, too many therapists are willing to go along with this system.

These same insurance companies made me a Provider. I believe they use the word “provider” as a way to address doctors, nurses, therapists of every variety, even syringe suppliers, with the same form letter. Because a “provider” need not be a doctor, the term also includes the numerous “physician-extenders” who do things that doctors used to do. Many Americans have insurance that obligates them to choose a doctor from a company list or “provider panel.” Even though I don’t participate on insurance company “provider panels” (they rarely allow for confidential, insight-oriented psychotherapy), I have received many a “Dear Provider” letter—impersonal, bureaucratic and, typically, unsigned.

Then came the Health Insurance Portability and Accountability Act (HIPAA), which made me an Entity. HIPAA was intended to help workers maintain their insurance when they changed jobs. It also directed the executive branch to develop regulations to protect medical privacy. While the rules provide new protection for psychotherapy notes, they also allow large companies (including pharmacies) to use personal health information for all sorts of nonmedical (commercial) purposes—without patients’ knowledge or consent. (Perhaps you have received a phone call from a company attempting to sell you products for an illness you thought was confidential?) In addition, the rules require hospitals and most doctors to carry out a lot of bureaucratic paperwork to make a display of privacy protection. You’ve probably signed forms at your doctor’s office to satisfy the rule that the office show you its privacy policies.

If I were to send patient information electronically—such as sending a bill to an insurer online—I would become a Covered Entity and would be forced to have my patients sign the useless forms. But, concerned about these electronic transmissions as an additional risk to confidentiality, I choose not to use them. This makes me a Non-Covered Entity. I’d prefer to be a doctor, but as an Entity, I’d much rather be Non-Covered than Covered.

Not everyone feels as I do. My internist now types on a notebook computer as we talk. Although electronic records are lost, stolen, and sold every day, he does not believe that the electronic record jeopardizes my privacy. If my records were accidentally or maliciously posted on the Internet, would they even be accurate? The problems listed on my billing slip are not necessarily those I consider important. They seem more oriented to justify to a potential third-party reviewer the substantial amount of time my doctor spends with me than an accurate description of my concerns. Would I tell him of problems about which I felt deeply embarrassed?
Now health care reform is in the wind again, and with it many questions. Will insurance companies still be allowed to skim 20% from each health care dollar? Will doctors still be reimbursed huge sums for procedures but pennies for talking with and understanding patients and their families? Can medicine be personal and private? Will people be taken care of by a doctor, a provider, or an entity?

My practice remains personal and private. Most of my patients address me as “Doctor,” but some call me Larry. I’m not particular about this: more important is that the patient be comfortable. If the patient has a strong preference about what to call me, we have the chance to learn from it. The patient’s feelings about addressing me may shed light on his or her feelings in other relationships.

Recently, the federal government has required all doctors (including this Provider/Non-Covered Entity) to have a National Provider Identification (NPI) number. It is 10 digits long, so it’s not easy to address me by it. But even if you are the bureaucrat who created NPIs, your secret will be secure with me.

Lawrence D. Blum, MD
Dr Blum is a psychoanalyst and psychiatrist in private practice in Philadelphia and in Cherry Hill, NJ. Read more!

The Couch in Crisis: Join the Fray!

I couldn't help but notice that it has become possible lately to lift recent editions of the Sunday New York Times with only a single hand. Not too long ago, the Sunday edition had a lot more reassuring heft to it.

If you are a print lover like me, it's hard to ignore the diminishing girth of most newspapers, magazines, and journals these days. Reeling from a sharp drop in advertising, many print publications have become fashionably lean. Even the mighty New York Times is not immune. As things go from bad to just totally terrible for the beleaguered newspaper industry, as a reporter from Forbes recently noted, headlines regularly announce the demise of venerable news publications.

Things aren't as dire for medical publications—although advertising support for medical journals has slipped in the past couple of years. According to industry sources, overall ad revenues for the multispecialty medical journals dropped by about 19% between 2007 and 2008. Among the psychiatric journals, advertising is down by about 8% for the same period.

This matters because fewer ads mean smaller issues and less clinical content that can be presented in each issue.

Psychiatric Times has also felt the impact. Although PT continues to enjoy its "most popular" psychiatric journal status among readers, the past several months have seen fewer pages of editorial content. We are still able to present a plethora of information . . . short news reports, insightful commentaries, and in-depth peer-reviewed clinical articles written by experts in the field. But we are increasingly focused on bringing to you online the PT you've always enjoyed in print—and then some.

Let me invite you to log on to http://www.psychiatrictimes.com/ and have a look around. Among the "extras" you'll find online (in addition to the articles that appear in each issue) are tips on managing your practice; guidelines for protecting yourself from malpractice; online symposia, with which you can earn CME credits; downloadable clinical scales; and "What's Your Opinion?" surveys.

Over the next few months, we'll be upgrading our Web site and adding more new features. Our goal is to make it a one-stop online community for all things psychiatric. For starters, we are introducing this blog—The Couch in Crisis—in which we hope you and your colleagues will air and share your views on issues important to psychiatrists.

I invite you to send us your comments about what you see as the key issues that currently face the practice of clinical psychiatry. Tell us what the most pressing challenges are that you face in your daily practice. Please don't hold back on telling colleagues why you choose—or do not choose—to continue to practice psychiatry.

We are kicking off that forum with an essay we recently received from Lawrence D. Blum, MD, a psychoanalyst and psychiatrist in private practice in Philadelphia and in Cherry Hill, NJ. Dr Blum's essay speaks in a light-hearted way to some changing trends in psychiatry. He begins: I used to be a doctor. Next I was a provider. Now, I'm a non-covered entity. I liked being a doctor—I still do. I never liked being a provider. But being a non-covered entity is a secret victory. I'll explain.


We've posted Dr Blum's essay on our Web site, where we hope to post your follow-up comments. By the way, your comments need not be as formal or as elegant as those of Dr Blum. We also welcome brief and informal views, comments, and opinions. Please send them to us.

We hope you like what you are seeing each month in PT—and we hope you'll like more of the PT that's heading your way via our Web site. Read more!